Do You Want to Know How to Defend Appropriate Charges?

A Few Facts about the Natural History of Spinal Conditions

1. 85% of pain patients are better in six weeks;


2. There is a high recurrence rate.


3. A slower recovery is expected if any of the following are present:


• history of greater than four episodes;¹


• severe pain;¹


• pain for more than seven days before seeing doctor;¹


• sciatica;^2,3


• job dissatisfaction;^2,3


• abnormal illness behavior;^2,3


• job disability in the previous 12 months;³


• decreased cardiovascular fitness;³


• decreased static trunk extension endurance.³


4. Treatment known to slow recovery:


• bed rest


5. Treatments known to speed recovery:


• manipulation in acute low back pain;


• McKenzie in acute low back pain;


• education in acute low back pain;


• stabilization exercises in lumbar radiculopathy and failed back surgery syndrome;


• resistance exercises in chronic low back pain;


• multidisciplinary functional restoration in chronic low back pain.

How to Defend Your Appropriate Billable Charge

1. Use outcomes to document patient progress.

• VAS starting day one and then every two weeks.⁴
• Oswestry or Neck Disability Index (NDI) starting day one and then every two weeks.⁴

2. Transition patients from passive to active care procedures before the end of six weeks.

To quote the Mercy guidelines: "All episodes of symptoms that remain unchanged for 2-3 weeks should be evaluated for risk factors of pending chronicity. Patients at risk for becoming chronic should have treatment plans altered to de-emphasize passive care and refocus on active care approaches." (Reference 1, p. 125)

The Mercy document also states: "It is beneficial to proceed to rehabilitation phase as rapidly as possible, and to minimize dependency upon passive forms of treatment/care." (p. 110)

Document in your SOAP notes that you are assessing for functional deficits and treating with exercise and patient education.

3. Document the presence of factors which slow recovery (see above list):

• Use CareTrack Patient History Form.⁴
• Use SF-36.⁴
• Use CareTrack Patient Classification Form.⁴
• Perform Waddell's tests for abnormal illness behavior.
• Perform Sorensen's static back extensor endurance test on subacute patients.

4) Establish end points (or goals) of care based on identifiable activity intolerances.

According to the guidelines of the AHCPR on acute low back pain in adults, the goal in treating back pain is to reduce activity limitations/intolerances due to pain.² The "functional restoration" model also focuses on restoration of functional, not just pain relief as a goal for care. Objective ways to capture information about such functional end points of care include:

• Oswestry: sitting, standing, lifting etc.
• NDI: driving, reading, sleeping, etc.
• SF-36: carrying, walking, etc.

This information once obtained should be included in your reports under the section, "End Points of Care." Removing the subluxation complex may be a means to this end, but reducing activity limitations caused by pain is a more appropriate goal for our patients and society.

Conclusion

Use of the Oswestry and NDI Questionnaires:

• as outcomes to measure functional progress every two weeks; to identify activity intolerances and end points of care; use of the VAS.


• as an outcome to measure symptom progress every two weeks; use of the SF-36; to identify psychosocial risk factors of a slow recovery; to identify activity intolerances and end points of care; use of CareTrack Classification Checklist;


• to perform diagnostic triage as per AHCPR instructions; use of CareTrack Patient History Form; to obtain risk factors of a slow recovery.

We have a golden opportunity to prove that we are the most cost-effective front line for managing neuromusculoskeletal conditions. It is time that we prove that we can beat the natural history of spine disorders. Only with outcomes and proper documentation can we create the national database necessary to accomplish this.⁴ Such a database can be used to negotiate successfully for capitated contracts in the very competitive health care marketplace. Quality care will improve customer satisfaction, reduce disability, and cut health care costs thus insuring chiropractors fair reimbursement from their own PPOs.

References

1. Haldeman S, Chapman-Smith D, Petersen DM. Frequency and duration of care. In: Guidelines for Chiropractic Quality Assurance and Practice Parameters. Aspen 1993, Gaithersburg.
2. Bigos S, Bowyer O, Braen G, et al. Acute low back problems in adults. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1994.
3. Waddell G, Feder G, McIntosh A, Lewis M, Hutchinson A. (1996) Low Back Pain Evidence Review. London: Royal College of General Practitioners.
4. CareTrack Outcome System. Grand Rapids, MN (800) 950-8133.

Craig Liebenson, DC
Los Angeles, California